ATI Finals As Derived From ATI Text For Nursing Fundamentals, Part II

Planning for several rest periods during morning care will help prevent fatigue and continue to foster independence. Fatigue and dyspnea are not reasons to eliminate morning care. Performing all of the client's care or having a family member do it will reduce the client's independence.

A high fiber diet promotes normal bowel elimination. Fruits and toast is a high fiber option. Noodles with beef tips, mashed potatoes with gravy, and macaroni with cheese are low fiber food

Unrelieved pressure over a bony prominence for a long period increase risk for skin breakdown. Sitting up in a chair will help prevent stasis of secretions. Muscle atrophy and fecal impaction would be complications for a client on prolonged bed rest.

Flushing the tube after feeding has been given helps maintain the patency of the tube by clearing any excess formula from the tube. If client requires more fluid, the small amount used for flushing will not be sufficient. If formula is to be diluted, it should be done before instilling the feeding. Flushing the tubes does not maintain proper placement

Pain is subjective. The client is the best source of information. It is a misconception to think that clients exaggerate their pain level. Clients can have pain without being able to identify where it is coming from. Objective data are not always there when a client is in pain.

Fluid intake is even more needed with excessive, vigorous training in high altitudes. It should also be increased in dry climates. Caffeine should be avoided because it may lead to dehydration.

Because of possible interactions between any type of drugs, it is not safe to self administer an OTC drug without the prior knowledge of the physician who prescribed regular medication. Consulting the physician before taking an OTC drug is the only teaching that can be done. The others are either irrelevant, not true or plain nonsense.

The correct answer explains that as pain continues, the body's sympathetic response decreases and the parasympathetic nervous system takes over. This means that even though the client may still be experiencing pain, there may not be any physical signs or symptoms of pain such as muscle tension. This can be due to the body's adaptation to pain over time.

Fowler's position facilitates maximal lung expansion and thus optimizes breathing. Supine, dorsal recumbent and lateral positions will not do this.

The greatest risk to this client receiving enteral feeding is aspiration pneumonia. Therefore, the first action the nurse should take is to stop the feeding so that nor more formula can travel to the lungs. Auscultating for breath sounds, obtaining a chest x-ray, and providing oxygen are all important actions, but none of them is the highest priority.

Ethnocentrism is the belief that one's own culture is superior to others. Socialization refers to a person's upbringing within a culture that results in becoming a practicing member of the culture. Repatterning refers to helping clients shift their belief to make them compatible with health promotion. Acculturation refers to the degree to which a client adopts the behaviors of a new dominant culture.

A clogged catheter causes the bladder to fill and stimulates the need to urinate. Reassuring the client that it is not possible to urinate is a nontherapeutic response. The patency of the tube must be checked before replacing the client's catheter. It is not necessary to contact the provider. The nurse can determine whether or not the tube is patent and replace the tube if necessary without a new order.

Sublingual drugs are properly administered when placed under the tongue until they are dissolved. They are readily absorbed into the blood stream for systemic effects. They should not be crushed or taken with water. Medications places between the cheek and gums are delivered through the buccal route. The medication should dissolve and is usually used for local effects.

Most nosocomial infections develop in the urinary tract, and regular cleaning of the perineal area along with catheter care reduces the number of micro-organisms. Assessing the patient's ability to void independently, placing an absorbent pad under the patient, and giving the patient a diet high in fiber will not prevent a nosocomial infection.

Nausea and vomiting are common associated symptoms experienced with pain. The location of the pain is where the client feels the pain is. Pain quality is assessed by identifying what the pain feels like, such as throbbing and aggravating. Aggravating and relieving factors are what might make the pain better or worse.

Using an incentive spirometer helps keep the airways open and prevents atelectasis. Isometric exercises strengthen skeletal muscles. Suctioning should not be done routinely. Low dose heparin helps prevent thrombus formation and avoids a possible ischemia

The second nurse should offer to assist the client needing the bedpan. This will allow the nurse who prepared the injection to administer it. A nurse should only administer medications that he/she prepared. Preparing another syringe will delay the administration of the needed pain medication. Telling the client to waist is not an acceptable option for the client needing the bedpan.

Tolerance occurs over time and the client will experience a decrease in responsiveness to a medication. The place effect occurs when the client experiences a positive effect due to a psychological factor. Accumulation occurs with an increase in medication concentration in the body due to inability to metabolize or excrete a medication rapidly enough, resulting in a toxic medication effect. Dependence is experienced as a psychological or physiological need for the medication.

The purpose of a SCD is to promote venous return. It does NOT PREVENT bed sores or muscular atrophy, and they do not increase joint mobility.

The least restrictive action is to allow the client to follow her usual bedtime routine to promote sleep. Rubbing her back, offering warm milk and crackers and requesting a sleeping medication may be necessary if this intervention is unsuccessful.

NG tubes are short term and can be inserted through the nose. Insertion of a gastrostomy or jejunostomy is done by a surgical procedure, and a percutaneous endoscopic gastrostomy (PEG) tube is inserted endoscopically. Surgical and endoscopic insertion presents a risk for injury and infection; therefore they are only indicated for long term use.

A pain scale can help the patient measure the amount of pain he has and its intensity. Assessment of pain triggers and identification of the location of the client's pain will provide valuable information to help select pain-control interventions. Neither provides information about pain intensity. Asking open-ended questions is important but it will nor provide consistent quantification of pain intensity

Most of the body's energy comes from carbohydrates. Fat provides energy but should be less than 30% of total caloric intake. Protein is responsible for growth and repair of body tissues. Vitamins do not provide energy

Privacy during catherization maintains dignity. Insertion of a urinary catheter requires surgical asepsis, because it is an invasive procedure. Supine position with knees bent and apart allows and easy insertion of the catheter. It is not necessary to darken the room and talking will not contaminate the sterile field.

Chiropractors use their hands to manipulate the spin. Acupuncture involves needles or pressure. Naturopathic medicine uses herbal remedies. Therapeutic touch practitioners use their hands to balance energy fields

Limited mobility as a result of a stroke (CVA) puts this patient at risk for skin breakdown. She is well-hydrated and nourished, and there are no data to indicate that she has urinary or fecal incontinence.

A stage III ulcer may extend past all the layers of the skin and subcutaneous tissue to the muscle. Reddened skin that does not blanch is Stage I. An abrasion or a blister is seen with STAGE II. Exposed bone is a Stage IV.

Providing privacy and time for the reading of religious materials supports the client's spiritual health. Contacting the hospital's spiritual services presumes there is a problem. Asking the client about the crying or providing a distraction could be interpreted as discounting or being disrespectful of the client's beliefs.

For fecal occult blood testing at home, the stool specimens cannot be contaminated with water or urine; three specimens from three different bowel movements are required; some proteins such as red meat, fish and poultry can change the test results; a blue color indicates blood in stool

BMI = weight (kg) / height (m2).
BMI = 80 / 1.62 m to the second power = 80 / 2.56 = 31.25 = 31
A BMI above 30 identifies obesity, so this client is considered obese

The most natural and efficient way to urinate is while sitting upright. Left lateral Sim's and right lateral positions are not appropriate for urine collection. The supine position makes it difficult to empty the bladder completely.

Labored breathing, such as dyspnea, apnea, and Cheyne-Stokes respirations are common when a client approaches death.

If a single dose requires multiple tablets, it is possible that an error has occurred in the transcription of the order. Errors may be prevented by taking unit-dose medications out of the wrapper at the bedside. Looking up usual dosage range prior to giving a medication may uncover an inaccurate dosage. If the order is unclear, the nurse must contact the prescribing physician for clarification.

Tucking the chin when swallowing allows food to pass through the esophagus more easily. Thin liquids and using a straw both increase the client's risk for aspiration. Sitting for an hour after meals helps prevent gastroesophageal reflux and possible aspiration of the contents after a meal.

School-age children must have their dietary intake supervised to ensure adequate intake of protein and vitamins C and A. They tend to eat too many foods high in carbohydrates, fat and salt

The first voiding of the 240hour urine specimen is discarded, and the time is noted. All voiding are collected after that and kept in a container on ice. If a urinalysis is ordered, ask patient to urinate and pour the urine into a specimen container. If culture is ordered, ask patient to urinate first into the toilet, then stop midstream, and finish urinating in the specimen container. The specimen for a 24-hour collection is stored on ice.

The greatest risk to the client receiving enteral feedings is injury from aspiration. Therefore, the priority nursing assessment before starting an enteral feeding is to determine the tube's proper place. Assessing the client's level of consciousness, the presence only complications of tube feeding (diarrhea) and the freshness of the formula are important but are not the highest priority with this patient.

The nurse is responsible for observing medication side effects, monitoring for therapeutic benefits, and for maintaining an up-to-date knowledge base. The prescribing physician is responsible for ordering the right dosage and changing that dosage if side effects take place.

Medications that are given orally are taken directly to the liver from the GI tract through the hepatic portal circulation. Some medications will be completely inactivated as they pass through the liver, and thus no therapeutic effect will happen. These medications must be administered through a NONENTERAL ROUTE.

Clients may experience feelings of anger and guilt with pain. Clients who are cognitively impaired may not be able to express what they are feeling. Attitudes about pain vary among different cultures. A client can still sleep even when experiencing pain; clients need less pain medication when pain is treated before it worsens

It is important to encourage and help a patient to change positions EVERY 15 MINUTES while sitting down to prevent continuous pressure on any skin area. While in bed, the head of the client's bed should be elevated no more than 30 degrees to prevent skin breakdown from shearing forces in the sacral area. Donut-shaped cushions increase pressure on the sacral area. A gel foam or air cushion would be better.

A drug-drug interaction can cause an increased effect. If two of these medications cause drowsiness (CNS depression), they will have a synergistic effect and may increase CNS depression. Increasing CNS depression can progress from drowsiness to stupor as well as fatal respiratory depression. Lactose intolerance should not interfere with this client's medication. Trade name medications can be used, and nurse can administer each pill one at a time

Sanguineous drainage is bright red and the result of active bleeding. A watery appearance is characteristic of serous or serosanguineous drainage. Green or yellow and foul odor are typical of purulent drainage.

Providing information will help patient make an informed decision,. A provider's order is not required for relaxation therapy. Providing reassurance may negate the client's fear. Providing more information without validating this as a need may increase anxiety. The nurse should not give any therapy without informing the patient and obtaining his consent. Telling him to relax does not acknowledge the impact ot his anxiety

Dexamethasone is a steroid that may raise blood glucose. Amoxicillin, morphine and acetaminophen should not affect blood glucose levels.

Polymeric formulas are nutritionally complete. Modular formulas provide a single macronutrient. Elemental formulas are composed of predigested nutrients, and specialty formulas are designed to meet specific nutritional needs and are not nutritionally complete.